Management of The Violent Patient

Dr. Varalee AphinivesBhumibol Adulyadej Hospital

Is violence a problem in the ED?

Yes

Acts of violence resulting in death have occurred in 7% of major teaching hospitals.

The patient become violent in the first place

Acute intoxication

Metabolic disorder

Infectious disease

Cardiovascular disorder

Intracranial disorder

Acute withdrawal Trauma

Environmental injury

Psychiatric disorders

Hypoxia

What can be done preempt a violent episode?

1. Be aware of early sighs of impending violent behavior, such as agitation, abusive language, and challenges to authority.

2.Completely undress major trauma victims as soon as possible, removing any weapons on their persons.

3.Do not leave any instruments that can be used as weapons near a potentially violent patient

What is the initial approach a physician cantake to control an agitated or violent patient?

First approach to any agitated patient should be verbal descalation.

The physician should remind the patient is in a safe environment.

Improving the patient’s comfort.

Stationing security officers may dissuade further inappropriate behavior.

Most important, care providers must check their own emotion.

Yelling back or exchanging threats with the patient only further escalates the situation

What if doesn’t work?

Multiple different restraint techniques-Two-point restraint-Four-point restraintPrecaution: Physical restraints often mayincrease patients’ agitation

Chemical restraint-depends on what is cuasing the agitation.

Sometime both are neccessary

Chemical restraint

Two class of drugs

1.Butyrophenones such as halaperidol and droperidol

2.Benzodiazepine such as larazepam and diazepam

Butyrophenones

Haloperidol 5-10 mg iv (about two dose)

don’t give three dose( avoid toxicity)

Switch to benzodiazepine

Side effect is extrapyramidal or other dystonic reaction.hypotension is rare.

Prophylaxis with diphenhydramine or benztropine mesylate (Cogentin) for 2 to 3 days after.

Benzodiazepine

Sympathomimetic-induced(e.g.,amphetamine, PCP, and cocaine)

Preferred suppectd anticholinergic toxicity because they reduce CNS production of catecholamines

Initial dose :Diazepam 5 to 10 mg iv and repeated dosed of 2 to 10 mg every 20 to 30 minutes as need

Do I have any alternatives to restraining a patient?

Ideally, an ED should have isolation room which agitated patients can be placed

This room should be monitored easily(e.g.,through windows or video camera)

Emptied of any objects that can be used as weapons.

What can hospital do to decrease the risk of violence?

1.All unnecessary doors should be locked and access into the hospital limited to a few patrolled entrances.

2.Metal detectors should be used to screen patients and visitors for weapons.

3.Continuous-surveillance, closed-circuit television monitors help to ensure safety in the parking areas and the immediate grounds of the hospital.

4.Multiple methods of sommoning police or security must be available to the ED without having to go through the hospital operator.

5.Responding police or security officers should be trained and equipped appropriately.

6.Clear documentation in the medical record. 7.A comprehensive program patterned after the critical incident

stress debriefing model provide immediate and long-term psychological support.

Reference

Emergency Medicine Secrets third edition

Vincent j.Markovchick,MD, Facep Peter T. Pons,MD, Facep